USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 34
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Statement of cause of death. - Name, first, the DISEASE ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia; Broneko- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sur- eoma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of " Tumor" fer malignant neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Hacmorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," ctc., when a dofinite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septieuemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
4
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Norfolk (No: Popolatic
Joseph maxim blicham. 2 FULL NAME {If married or divorced woman or widow give maiden name disp name of, husband.] @RESIDENCE mithrof mass
St. ;....
. Ward)
Ovocfolk (City or/town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June 26
1911
(Year)
(Month )
(Day)
I HEREBY CERTIFY that I attended deceased from
June 24.
191, to
Janvie 26, 191.
If LESS than dạy ... hrs. that I last saw h- alive on , 19 .... . and that death occurred, on the date stated above, at ......... .... . m.
The CAUSE OF DEATH* was as follows :
acute nephritis
Contributory
arterio
(Duration)
yrs.
Sclerosis
mos.
ds.
(SECONDARY)
(Duration)
2 yrs. mos.
ds.
(Signed)
Goo. I. Yeaton
M.D.
time 26,
1911
(Address)
Medway
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death.
.yrs
. mos.
ds.
State .. ...... yrs.
mos.
ds ..........
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Buffalo
DATE OF BURIAL
191
ADDRESS
10 UNDERTAKER
Walter C. Palmer medway, marc.
important. See instructions on back of certificate.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
Arhite
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Oct.
8
(Month)
(Day)
7 AGE
60
yrs.
8
mos.
18
ds.
& OCCUPATION
Salesman
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment
in
which employed (or employer)
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
9 BIRTHPLACE
(State or country)
Liverpool, Cinq.
married
1850
(Year)
or ....... min. ?
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Sarah & Clickam
(Address)
File Jime 28 191. William M. Kill S. a. M. an EGISTRAR
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless in- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 175. main
St. ;.. Ward)
francie gration ghite. 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 175 Main St. Tuttiofn +142
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
-
x
6 DATE OF BIRTH
10
28
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, .. . hrs.
36 yrs ..
7
mos.
29.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work Housewives
(b) General nature of industry, business, or establishment in which employed ( or employer)
9 BIRTHPLACE
(State or country)
Scotland
10 NAME OF
FATHER
Tomar Hatson.
11 BIRTHPLACE OF FATHER (State or country)
quand
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1
(Informant)
James his
(Address)
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
Jance
27
(Day)
I HEREBY CERTIFY that I attended deceased from
Jan
191./., to ..
fre 27, 191.
that Mast saw h 2 alive on
6 , 191) , and that death occurred, on the date stated above, at /2 m.
The CAUSE OF DEATH* was as follows :
Carcinoma of uturus
(Duration)
1
yrs. .
mos. ..
ds.
Contributory ...
(SECONDARY)
( Duration)
mos. . ds.
31 mitTal)
yrs.
M. D.
...
191 .. . f. (Address)
Washap mois
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs. ...
. mos.
ds.
State
In the
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?...
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
00 UNDERTAKER
ADDRESS
272- a- 10x
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
19! 1 (Year)
1854
17
(Signed)
PARENTS
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loeo- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have 110 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of ... (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasıns) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be state? unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("('ongenital," "Senile," etc.), " Dropsy," " Exhaustion," " Heart failure," " Haemorrhage," " Inanition," " Marasmu"," "Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," ctc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc. - 3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Windlach (CITY OR TOWN.)
FULL NAME
Celiales augusto Casco
.Registered No.
Place of l
328 Pleasant Sol Nunchuck
Date of ¿
June 27
Death S
19//.
Residence
Age
.years.
X
months. days
STATISTICAL DETAILS
SEX
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE# Copenhagen Denmark
NAME OF FATHER
1
BIRTHPLACE OF FATHER+
(DURATION) ....... 2 .- OFFS
(Signed)
D. L. Jackson
M.D.
June 29 19/1 (Address)
562 Shirley 88 .
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at Place of Death ? . years ...................... months. ..................... days
Where was disease contracted, If not at place of death ?.
Filed
9
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country } also city, town or county, If known.
§ Name and address of person giving statistical details. I{ Name of cemetery.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL Juin 29 19 /‹
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 1
to .. Jane 221961, 19 /1 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Senility
(DURATION). ..... .. DAYS
Contributory :
Chronic Prostatitis.
MAIDEN NAME
OF MOTHER
7.
BIRTHPLACE
OF MOTHER #
OCCUPATION Retireel Lia Caflan-
INFORMANT §
UNDERTAKER ER Bemna
---
Death *
5
June 27, 1911
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME OF MOTHER
Mary Janery
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Factur
(Address)
mulherof
15
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
28
(Month)
(Day)
, 1914
(Year)
17 HEREBY CERTIFY that I attended deceased from 1
(Year)
June 18
191.1 , to
June 28, 1911,
that I last saw her
alive on
June 2 8, 1911.
a
and that death occurred, on the date stated above, at/0,3cm.
The CAUSE OF DEATH* was as follows :
acute meningitis
Total duration of illness 10 days.
(Duration)
yrs.
mos. ..
ds.
Contributory
Teute Lobar Pneumoniaq
(SECONDARY)
measles
.(Duration)
yrs.
mos.
. . .. .. ds.
(Signed)
2. 03. Hunley
..
M.D.
June 28, 1911 (Address)
20 Chelsea 80 S.B
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
mos.
ds.
State
In the
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Huty Cava Maldi
DATE OF BURIAL 27.1911
ADDRESS
.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX D
6 DATE OF BIRTH
7 AGE
1
yrs.
2
mos.
ds.
or min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (State or country)
Bastin
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON (City or town.)
1 PLACE OF DEATH
(No.
275 Mannis
St. ;.. .
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Elline
15 allows
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 278 Marry LL Muchos
Registered No.
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
(Month) (Day)
If LESS than
1 day, .
hrs.
20 UNDERTAKER
0
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE ( AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Elizabet Borden
(CITY OR TOWN.)
Registered No.
Place of
$1 Thousands Park Withers
Date of ¿ · Fine 29 Death
19/1
Residence
Age
.years.
K
.months. 17 .days
STATISTICAL DETAILS
SEX finale
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # nuchính mais
NAME OF FATHER Clientes. 711. Borden
BIRTHPLACE
OF FATHER$
Pugwash. Novaleda-
MAIDEN NAME OF MOTHER Myrnah . Ledden
BIRTHPLACE OF MOTHER$ auburn Mais
OCCUPATION
INFORMANT §
Filed
..... 19
Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
19//
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
A I HEREBY CERTIFY that I attended deceased during last illness, from. May 29' .19 /1 to que 29 .. 19 / ' , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Premature. Primary : Lack of vitality
(DURATION) 17
.DAYS
Contributory :
.(DURATION) ..... DAYS
(Signed)
Bithitcall
M.D.
M
My 29 1911 (Address)
Wandrup mass
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? years ................. .......... months. ...... . days
Where was disease contracted, If not at place of death ?
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. |[ Name of cemetery.
E
ALL NAMES TO BE IN FULL
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
...
FULL NAME
Preva .
Death *
S
June 29, 1911
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH Westborough, Mass (No. Westboro State Hospitals.
Ward)
Weallora (City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
101
.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
4 by 1 st. 1911.
(Month)
(Day)
: 191 (Year)
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